Healthcare Provider Details

I. General information

NPI: 1568490605
Provider Name (Legal Business Name): EDWARD H HERSKOVITS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 S GREENE ST, DEPT OF RADIOLOGY
BALTIMORE MD
21201-1544
US

IV. Provider business mailing address

2825 OAK LAWN AVE UNIT 192749
DALLAS TX
75219-4688
US

V. Phone/Fax

Practice location:
  • Phone: 410-328-3477
  • Fax:
Mailing address:
  • Phone: 510-683-9500
  • Fax: 877-880-2039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberG61201
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberT9923
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number56124
License Number StateKY
# 4
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberG61201
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: